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Complications in the Treatment of Infant Hip Dysplasia

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Complications in the Treatment of Infant Hip Dysplasia Complications in the Treatment of Infant Hip Dysplasia 25 October, 2019 Aaron Boyles, DO Assistant Professor Children’s Hospital Colorado – Colorado Springs Colorado University School of Medicine 1 Disclosures None 2 Overview • Pavlik Harness • Closed reduction • Open reduction • Pelvic osteotomy Pavlik Harness Complications Femoral Nerve Palsy Occurs about 2.5% of the time 87% present in the first week Higher risk in older, larger patients with JBJS VOL. 93-A NUMBER 5 MARCH 2, 2011 more severe dysplasia Strong predictor of treatment failure 97% success w/o FNP vs. 47% with FNP Increased flexion has also been implicated1 1 Mubarak et al. JBJS VOL. 93-A NUMBER 5 MARCH 2, 2011 Femoral Nerve Palsy Treatment Immediate removal of harness Watch closely for recovery Reapply harness once resolved Consider decreasing hip flexion Watch closely for recurrence https://hipdysplasia.org/developmental-dysplasia-of-the-hip/child- treatment-methods/femoral-nerve-palsy/ Pavlik Harness Disease Historic teaching: abandon Pavlik if unsuccessful after 2-4 weeks Based on Jones et al1 paper? >8 weeks in harness potentiated dysplasia Recently this has been challenged Gornitzky et al2 showed no harm and improved α-angle in hips with average of 6 weeks in harness 1Jones et al J Pediatr Orthop. 1992 Nov-Dec;12(6):722-6. 2Gornitzky et al J Pediatr Orthop. 2018 Jul;38(6):297-304. Failure to Reduce in Pavlik More failures in Ortolani positive hips Up to 40%1 Higher failure risk in Graf IV hips (inverted labrum, α-angle <43°) 4.4 times higher risk of Pavlik failure2 1White, KK et al J Bone Joint Surg Am. 2010 Jan;92(1):113-20. 2Novias et al Clin Orthop Relat Res. 2016 Aug;474(8):1847-54. https://radiologyassistant.nl/pediatrics/developmental-dysplasia-of-the-hip- ultrasound Failure to Reduce in Pavlik: Treatment Rigid abduction bracing has been shown to be an effective 2nd line treatment option Rigid abduction orthosis after Pavlik failure was reported to have 87% success rate1 Hedequist showed 13 of 15 hips reduced in a semi-rigid abduction orthosis after Pavlik failure2 1Sankar et al J Bone Joint Surg Am. 2015 Feb 18;97(4):292-7. 2Hedequist et al J Pediatr Orthop. 2003 Mar-Apr;23(2):175-7. My Protocol Start with Pavlik Ultrasound and exam at 2 and 4 weeks Exam for femoral nerve palsy Transition to abduction orthosis if not stabilized in 4 weeks Ultrasound and exam at 6 and 8 weeks If no improvement at 8 weeks, abandon nonoperative treatment Proceed with Closed vs Open reduction at ~6 months Closed & Open Reduction Complications Skin Breakdown Spica casts have been reported to have skin complications up to 28% of the time1 Waterproof, breathable cast liners have been shown to decrease skin excoriation due to soiling form 22% to 1.4%2 1DiFazio et al J Pediatr Orthop. 2011 Jan-Feb;31(1):17-22. 2Wolff et al J Pediatr Orthop. 1995 May-Jun;15(3):386-8. https://hipdysplasia.org/patient-stories/advocate- spotlight/spica-life/ Buchholz-Ogden Classification Avascular Necrosis Incidence ranges widely 0-73%1 Inconsistent classification and follow up Some forms of AVN do not appear until 9 years or older 1Roposch, A., Wedge, J.H. & Riedl, G. Clin Orthop Relat Res (2012) 470: 3499. Avascular Necrosis – Predictors Ossific Nucleus? Segal et al showed that the ossific A more recent meta-analysis showed nucleus is protective against AVN1 no protective benefit3 This finding has since been Prospective level 2 study showed challenged by multiple authors AVN rates were unaffected by the One meta-analysis showed a ossific nucleus or age4 protective affect for more severe forms of AVN2 1Segal et al J Pediatr Orthop. 1999 Mar-Apr;19(2):177-84. 2Roposch et al J Bone Joint Surg Am. 2009 Apr;91(4):911-8. 3 Chen et al J Bone Joint Surg Am. 2017 May 3;99(9):760-767. 4Sankar et al J Pediatr Orthop. 2019 Mar;39(3):111-118. Avascular Necrosis – Predictors Abduction in cast Higher degrees of abduction have been associated with AVN Schur et al showed increase AVN rates in patients <6 months when abduction was >50° Jaramillo et at showed a correlation between increased abduction and decreased perfusion on MRI. Avascular Necrosis – The Utility of Perfusion MRI Gadolinium contrast MRI can show decreased femoral head and epiphyseal perfusion after spica casting1,2 This decrease has been linked to the development of AVN 1,2,3 MRI can guide treatment and may 1Jaramillo et at AJR 1998;170:1633-1637 2Tiderius et al J Pediatr Orthop 2009;29:14Y20 decrease the incidence of AVN4 3Haruno et al Journal of Pediatric Orthopaedics B 2019, 28:424–429 4Gornitzky et al Clin Orthop Relat Res (2016) 474:1153–1165 Avascular Necrosis Treatment Address resultant deformity Schneidmueller et at J Pediatr Orthop 2006;26:486Y490 Trochanteric overgrowth Greater trochanter epiphysiodesis Greater trochanteric advancement Relative femoral neck lengthening Femoral head deformity Osteochondroplasty Femoral head reduction Avascular Necrosis Treatment Coxa valga Varus osteotomy Guided Growth Address any LLD Contralateral epiphyseodesis Oh et al CORR 2005 Number 434, pp. Torode et al J Child Orthop (2015) 86–91 9:371–379 Re-dislocation Re-dislocation can happen after both Higher risk of re-dislocation after closed and open reduction open reduction when: Sankar et al reported 9% re- Right hip Bilateral dislocation after closed reduction1 Less abduction in cast 39° vs 51° and 5.9% after open redution2 1Sankar et al J Pediatr Orthop 2019;39:111–118 2Sanker et al J Pediatr Orthop 2011;31:232–239 Re-dislocation Failure of open reduction can also occur secondary to technical error 2 studies cite incomplete release of inferomedial capsular contracture and the transverse acetabular ligament as reasons for failure1,2 1Kershaw et al J Bone Joint Surg Br. 1993;75B:744–749. 2McCluskey et al J Pediatr Orthop. 1989;9:633–639. Schwend, RM 2011 Anterior Approach for Open Reduction of the Developmentally Dislocated Hip in Flynn, JM, Wiesel, SW (Ed.) Operative Techniques in Pediatric Orthopedics p. 473 Persistent Dysplasia - Predictors Initial IHDI classification has been shown to be predictive of need for future pelvic osteotomy after successful closed reduction Ramo et al J Pediatr Orthop 2018;38:16–21 Persistent Dysplasia - Treatment Pelvic osteotomy Salter, Pemberton, San Diego, Dega, Triple Indication Persistent elevation in acetabular index Shin at al suggest that the Center Edge Angle and Acetabular Index at age 3 can be used as a guideline Patients with AI ≥32° and/or CEA ≤14° were more likely to have a satisfactory outcome if osteotomy was performed Shin et al J Bone Joint Surg Am. 2016;98:952-7 Pelvic Osteotomy Complications Avascular Necrosis Higher rate with excessive inferior displacement of the proximal femur after Pemberton1 1Wu et al J Bone Joint Surg Am. 2010;92:2083-94 Femoroacetabular Impingement Castaneda et al reported that radiographic FAI occurred 12% of the time after innominate osteotomy 1 in 10 had clinically significant FAI A correction of the AI of more than 20° was a risk factor for developing FAI Summary Start with Pavlik Open reduction Monitor for femoral nerve palsy Release inferomedial capsule and TAL Consider abduction orthosis Amount of abduction in cast is still important Attempt brace treatment up to 8 weeks or longer if progress is seen on US AVN Closed reduction Monitor long term, may not appear until 9 year or older Use waterproof, breathable cast liner Limit abduction in cast to <50° Beware of IHDI 3 and 4 hips Don’t wait for the ossific nucleus Higher rate of failed closed reduction Perfusion MRI? Higher rate of later pelvic osteotomy Summary Monitor for acetabular remodeling Acetabular index > 32 at age 3 should prompt osteotomy Failure to progress by age 6 Pelvic osteotomy considerations Walk the line between instability and impingement Overcorrection can lead to AVN and FAI Questions? 28.
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